Provided by Coventry Health Care Texas Medical Bill Reviewer Training Program Unit 1: Professional...

Provided by Coventry Health Care

Texas Medical Bill Reviewer Training Program

Unit 1: Professional Services

Introduction and General Guidelines

©2011 Coventry Health Care. All rights reserved.Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.

Texas Regulations Training August 2011

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Overview

Howdy, I’m here to guide you on a tour of our Workers’ Compensation fee schedule rules. Together I’m sure we can become more familiar with the unique aspects of our guidelines.

Part I: General Information

History

Part II: Processing Guidelines

Separate Procedures

Unlisted Procedures

Special Reports

Modifiers

Calculating Reimbursements


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History

In 1913, Texas’s Workers’ Compensation laws were established. At the same time, the Texas

Industrial Accident Board was created to administer the

laws.

When the law was established, employers were allowed to choose whether to offer workers' compensation benefits to their employees.


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Texas Workers’ Compensation Act

In 1917, Texas revised its workers' compensation laws to require employers to choose whether or not to participate in

a state workers' compensation program.

Texas is the only state that allows employers to choose whether or not to provide workers'

compensation.

However, one exception exists: Employers entered in a building or construction contract with a government entity must provide workers'

compensation for all workers.


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TX Workers’ Compensation Act

The Texas Workers’ Compensation Act

provides for: Benefits are paid by:

Medical expenses Wage-loss compensation benefits Death benefits (for work- related deaths paid to dependent survivors)

Private insurance companies (including TPAs) State Workers’ Compensation Fund (a state-run workers’ comp carrier) Employers themselves, if self insured


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Texas Workers’ Compensation

InjuredWorkers

LaborUnions

InsuranceCompanies

Employers

Attorneys

ServiceProviders

RegulationAgencies

The Workers’ Compensation Program is a large melting pot of many different entities.


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General Information and Instructions

Part I: General Information History

Part II: Processing Guidelines Locator Codes Calculating Reimbursements Separate Procedures Procedures Without Unit Value Special Reports

Now that you are familiar with the framework of TX

Workers’ Comp, let’s take a look at some general guidelines and instructions.


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Locator Codes

Texas has 1 locator code in the BR4 system – 999

The code is determined by zip code location and impacts both professional and facility bills. Let’s take a look. . .

How do I find a locator code?


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Locator Codes

Step 1: Access Bill Review 4 Reference Materials


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Locator Codes

Step 2: Select State Reference Guides & U&C Guidelines.


Locator Codes

Step 3: Select Locality Tables under Internal Resources on the right side of the screen.


Locator Codes

Step 4: Find the provider’s zip code and the effective dateof service on the table to locate the provider’s fee schedule locality.


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Changing a Billed Procedure Code

There is a reluctance with most workers’ compensation departments and boards to allow payors to change billed codes.

This is seen as a possible way to manipulate payment without the provider’s permission.

In Texas, however, altering codes is allowed if the provider is called and notified of the change. Key the billed procedure in the Billed Proc field.

Let’s take a look at an example


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On this bill example, there is a Surgical DRG, a CPT code, which is billed for the Total Technical and Professional component and a surgical Revenue code.

CPT Code

Surgical DRG

Surgical Rev Code


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To change the code in the system, change the CPT code for the Technical component to the appropriate Revenue code by taking the following steps:

Line 4: CPT code 73500

billed as Total component (no

modifier)

Line 4: change CPT code 73500 to Professional component

(modifier 26)

Line 6: Rev code 320 keyed

for the Technical

component of 73500


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Separate Procedures

Some listed procedures are carried out as an integral part of a total service, while other procedures are independent of additional services.

Procedures that are integral parts of a total service DO NOT warrant separate identification or reimbursement.

Separate Procedure: a procedure independent of, and not immediately related to, other services performed, for which reimbursement is ALLOWED.


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Separate Procedures

For Example:

CPT 95851, which codes for a Range of Motion procedure, is an essential part of a

follow-up visit for a shoulder injury. Therefore, it WOULD NOT warrant separate

reimbursement.

However, if this procedure was the only service performed, it would be considered a

separate procedure and should be ALLOWED.


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If the necessity of the services has been verified and the service authorized, additional information may be

requested about the procedure or an online search may be performed.

Unlisted Procedures

Every effort should be made to identify the service performed

with a specific code rather than an unlisted procedure.

The unlisted code billed may represent a slightly different

version of an established code that would still be appropriate.


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Unlisted Procedures

Every effort should be made to identify the serviceperformed with a specific code rather than an unlistedprocedure code. • As you know,

providers

often misuse the unlisted

code when a more

appropriate code is

available.

Hmm, which code should I

use?


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Out-of-State Bills

All Texas claims, both in-state and out-of-

state, are paid by Texas WC fee schedule rules

and values.


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Special Reports

Special Reports (CPT 99080) are reports specifically requested by the insurer. Only certain types of reports are reimbursable. Follow the edit instructions.

Special Reports


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Special Reports

If this procedure code is keyed:

For this item: The system recommends:

99080, with modifier 69

Texas DOWC-69, Report of Medical Evaluation

Denial of charges

99080, with modifier 73

Work Status Report $15.00

99080 Narrative Report $100.00 for the first two pages, $40.00 per additional page

99080 1-2 page single spaced report

$50.00 for the first page


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Modifiers

Modifiers indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition.

Modifiers may indicate circumstances such as:

Only part of the whole procedure was performed.

A bilateral procedure was performed.

Modifiers will be

covered in the

context of billed

codes.


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Reimbursement rates are tied to Medicare rates.

All CPT and HCPCS codes are based on the 2011 Medicare

values.

DME codes are based on the 2011 DMEPOS

fee schedule guidelines.


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It is important to know that the bill review system calculates and applies the reimbursements for you.

But, as you can see, knowing how to calculate

reimbursements may help you identify errors during bill review or troubleshoot

problems when reviewing challenging bills.


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Summary

Description of separate procedures and unlisted procedures

Defined special reports How to calculate

reimbursements

TX Workers’ Comp Overview

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